Anticonvulsant hypersensitivity syndrome associated with reactivation of cytomegalovirus

Recently, it has been proposed that viral infection is involved in the pathogenesis of hypersensitivity syndrome. Cytomegalovirus (CMV), one of the aetiological agents of infectious mononucleosis, has never been reported as an organism associated with hypersensitivity syndrome. We describe a 64-year-old man with severe phenytoin-induced hypersensitivity syndrome associated with CMV infection. Twenty-five days after the patient was started on phenytoin, he developed high fever and a generalized erythematous rash followed by jaundice, renal failure and disseminated intravascular coagulopathy (DIC). CMV-specific IgG antibodies were significantly increased 7 weeks after the onset of clinical symptoms and the increase was associated with the appearance of CMV-specific IgM. CMV DNA was detected in the serum of the patient. Coinfection with other viruses, such as Epstein-Barr virus and human herpesviruses 6 and 7, could be excluded because antibody titres to those viruses did not increase during the clinical course of his illness. We suggest that reactivation of CMV may contribute, at least in some cases, to the development of hypersensitivity syndrome.

Hospital outbreak of MEN-1-derived extended spectrum beta-lactamase-producing Klebsiella pneumoniae

An outbreak of Klebsiella pneumoniae resistant to broad spectrum cephalosporins occurred in a hospital in the Kinki area in Japan. During 18 months, from February 1998 to July 1999, 23 strains were isolated from 21 patients (10 with pneumonia, 4 with urinary tract infection, 1 with sepsis, 1 with vaginosis, 1 with a wound infection, and 1 with both pneumonia and sepsis; 3 patients showed noninfective colonization with K. pneumoniae) in seven wards, including the intensive care unit. MEN-1-derived gene was detected by polymerase chain reaction from the majority of the strains. Ninety-nine strains of K. pneumoniae were isolated during this period. The isolation rate of K. pneumoniae resistant to broad spectrum cephalosporins was 21%. We distinguished three clones by pulsed-field gel electrophoresis and randomly amplified polymorphic DNA analysis, and one of them was isolated from 18 patients. The presence of an R-plasmid of more than 160 kb was confirmed by plasmid analysis, but it was not possible to obtain transconjugants from all strains. This outbreak of K. pneumoniae was immediately confirmed by genetic analysis, and it was promptly ended by the infection control procedures. This is the first hospital outbreak of MEN-1-producing K. pneumoniae in Japan.

Liver abscess caused by Clostridium difficile

We report the first case of an infected cyst and liver abscess caused by Clostridium difficile. It recurred 11 months later, despite therapy with vancomycin and percutaneous drainage. Administration of metronidazole following percutaneous drainage achieved a favorable outcome.

Regulation of LPS induced IL-12 production by IFN-gamma and IL-4 through intracellular glutathione status in human alveolar macrophages

Interleukin-12 (IL-12) is secreted from monocytes and macrophages; it exerts pleiotropic effects on T cells and natural killer (NK) cells, and stimulates interferon-gamma (IFN-gamma) secretion. Glutathione tripeptide regulates the intracellular redox status and other aspects of cell physiology. We examined whether IFN-gamma and IL-4 affect the balance between intracellular reduced glutathione (GSH) and oxidized (GSSG) glutathione, as this may affect IL-12 production in human alveolar macrophages (AM). We used both AM from healthy non-smokers obtained by bronchoalveolar lavage and the monocytic THP-1 cell line in this study. Incubation of AM for 2 h with the GSH precursor N-acetylcysteine (NAC) increased the intracellular GSH/GSSG ratio, and enhanced lipopolysaccharide (LPS)-induced IL-12 secretion by AM. In THP-1 cells, NAC increased the GSH/GSSG ratio and the expression of LPS-induced IL-12 mRNA, whereas L-buthionine-[S,R]-sulphoximine (BSO) decreased these. NAC and BSO offset their own effects on the intracellular GSH/GSSG ratio and the expression of LPS-induced IL-12 mRNA. Furthermore, exposure of AM to the helper T cell type 1 (Th1) cytokine IFN-gamma or the helper T cell type 2 (Th2) cytokine IL-4 for 72 h increased and decreased the GSH/GSSG ratio, respectively. Lipopolysaccharide (LPS)-induced secretion of IL-12 in AM was enhanced by IFN-gamma but inhibited by IL-4. These results suggest that IFN-gamma and IL-4 oppositely affect the GSH/GSSG balance, which may regulate IL-12 secretion from AM in response to LPS.

Effects of N-acetylcysteine and ambroxol on the production of IL-12 and IL-10 in human alveolar macrophages

BACKGROUND

N-acetylcysteine (NAC) and ambroxol (AMB) have recently been proposed as possible therapeutic agents in the treatment of pulmonary disorders. IL-12 plays an important role in host resistance to infection and the development of Th-1 cells. In contrast, IL-10 is involved in anti-inflammatory and immunoregulatory mechanisms.

OBJECTIVE

We investigated the effects of NAC and AMB on secretions of IL-12 and IL-10 from human alveolar macrophages.

METHODS

Alveolar macrophages were obtained from 7 healthy nonsmokers by bronchoalveolar lavage. The cells were first incubated with either NAC or AMB for 2 h and then cultured in lipopolysaccharide (LPS) solution for 24 h. IL-12 and IL-10 secretions were measured by ELISA.

RESULT

Both NAC and AMB enhanced LPS-induced secretion of IL-12. NAC also enhanced LPS-induced IL-10 secretion, while AMB did not. The ratio IL-12/IL-10 secretion was increased by AMB, but NAC did not affect it.

CONCLUSIONS

The results suggest that NAC enhances inflammatory and immune responses and prevents excessive responses reciprocally, through keeping local balance of IL-12 and IL-10 production in alveolar macrophages at inflammatory sites of bacterial pneumonia. AMB appears to strengthen inflammatory responses and cell-mediated immunity, facilitating the development of Th-1 cells, through shifting the local balance to IL-12 dominance.

Contact urticaria from rice

A 30-year-old man with atopic dermatitis had had erythema and itching of the hands after washing rice in water, though he had always eaten cooked rice without problems. Handling test with water used to wash regular rice was performed on abraded hands, and produced urticarial erythema after several minutes. Applications of water used to wash allergen-reduced rice were negative for urticarial reaction. Prick test with water used to wash regular rice was +++. However prick test reaction with water used to wash allergen-reduced rice was +. Histamine-release test of regular rice-washing water was grade 3 and that of allergen-reduced rice grade 1. In immunoblotting analysis with regular rice washing water, there were no bands with this patient. These results suggest that the allergen responsible for contact urticaria in this patient might be water-soluble, heat-unstable, and not contained in allergen-reduced rice.

[Pseudomonas aeruginosa]

We investigated the causes of nosocomial infection of P. aeruginosa in a recent outbreak of P. aeruginosa in our hospital. Multi-drug-resistant-P. aeruginosa(MDRPS) that did not produce class B beta-lactamase was isolated from 20(40.0%) patients, occurring in 50 patients hospitalized in the Internal Medicine Ward E in our hospital in 1999 was investigated. All of the patients had brain-vesicular damage as the underlying disease, and 12 patients had been fed by nasal feeding or through a gastric stoma. MDRPS was isolated from sputum(7), urine samples(8), wound discharge(4) and 1 catheter. The bacteria were resistant to piperacillin, ceftazidime, sulbactam/cefoperazone, minocycline and ofloxacin, and in 40% the MIC of the imipenem was more than 8 micrograms/ml. We did not detect MDRPS in any equipment parts or waste water, including the sink in Ward E, but it was detected in the nutrient fluid for nasal feeding and in the line of one patient. The DNA homology of MDRPS isolated from the patient and the nutritive liquid was the same as that of some strains isolated in Ward E, as shown by random amplified DNA polymorphism PCR. In conclusion, we speculated that some nosocomial infections due to MDRPS resistant to imipenem were caused by contaminated nasal feeding.

Midgut malrotation in adulthood

A 29-year-old man was admitted to our hospital with a history of recurrent right upper quadrant abdominal pain and vomiting. These symptoms appeared intermittently for 7 years. Various examinations revealed a diagnosis of midgut malrotation. Laparotomy was performed and revealed reverse rotation of the duodenum with paraduodenal hernia and a normal rotating colon. This case suggests that recurrent abdominal complaints in an adult should arouse suspicion of midgut malrotation.

[A relationship between a psychosomatic and a skin condition in patients with atopic dermatitis]

Atopic dermatitis (AD) has been clinically well-known to be frequently exacerbated by some psychosomatic stress. In this study, we examined a relationship between a psychosomatic and a skin condition in patients with AD. Visual analogue scale (VAS) for the grade of general physical condition, mental stress and others were reported daily for themselves, while skin physiological parameters, resident skin bacteria and a psychological questionnaire (POMS) were measured every 2 weeks. It was observed that tense-anxious and depressive scores of POMS tended to correlate with skin conductance, a skin clinical score and a number of total skin bacteria and others. These results suggest that changes of psychosomatic condition reciprocally correlate with the exacerbation and improvement of skin symptom in patients with AD.

[A case of atopic dermatitis which showed correlation of psychological state and lesions--changes of value of psychological test, skin lesion and NK cell activity]

The relationship between psychological state and skin lesions of atopic dermatitis were investigated with a 31-year-old male patient. He had severe atopic dermatitis which became worse with psychological stress. A psychological test, profile of mood states (POMS), was performed on him every 2 weeks. Peripheral lymphocytes and natural killer (NK) cell activity were investigated at some points. When the psychological state showed more depressive, anxiety, anger, fatigue and confusion, the skin lesions became worse and recovered after the psychological states turned well. Correlation was shown between itch and stress or fatigue by a visual analogue scale (VAS) (p < 0.001). NK cell activity decreased during the worse psychological state and recovered during the near normal psychological state, although, the lymphocyte count and CD4/8 ratio in peripheral blood did not change during the study. These results suggest that some patients with atopic dermatitis should be treated psychologically in addition to standard dermatological treatment.

Expression of lysophosphatidic acid receptor in rat astrocytes: mitogenic effect and expression of neurotrophic genes

Lysophosphatidic acid (LPA) is a phospholipid mediator with a variety of biological activities. It remains unknown, however, which cells in the brain express the LPA receptor. The present study was undertaken to identify cells in the rat brain expressing functional LPA receptors, and to explore biological roles of LPA in these cells. We found that the LPA receptor was most dominantly expressed in rat astrocytes, determined by LPA-induced Ca2+ imaging, and by Northern blot analyses. LPA induced a mitogenic response and expression of immediate early genes in astrocytes, through pertussis-toxin sensitive G-protein(s). LPA also stimulated the expression of various cytokine genes, including nerve growth factor, interleukin (IL)-1beta, IL-3 and IL-6. Thus, astrocytes are the major target of LPA in the brain. We propose that LPA may play important roles in neuronal development, gliosis and wound-healing process in the brain.

Interaction between neurone and microglia mediated by platelet-activating factor

BACKGROUND

Platelet-activating factor (PAF) is a potent phospholipid mediator that plays various roles in neuronal function and brain development. The production and release of PAF in the brain has also been reported under various pathological conditions. However, neither the cell types and mechanism responsible for the synthesis of PAF nor its target cells have been fully identified.

RESULTS

Using primary culture cells derived from rat brain and a very sensitive assay method for PAF, we found that PAF was synthesized in neurones following stimulation with glutamic acid. PAF synthesis required activation of NMDA receptors and subsequent elevation of intracellular calcium ions. Microglia, which express functional PAF receptors to a high level, showed a marked chemotactic response to PAF. This chemotaxis is a receptor-mediated process, as microglia from PAF-receptor-deficient mice did not show such a response. The activation of a pertussis-toxin-sensitive G-protein and mitogen-activated protein kinase presumably plays a role in intracellular signalling leading to chemotaxis.

CONCLUSIONS

Considering the cytoprotective and cytotoxic roles of microglia, PAF functions as a key messenger in neurone-microglial interactions.

[Evaluation of MAST-26, newly developed system for the detection of IgE antibodies]

MAST-26 is a new allergy testing system which allows simultaneous determination of allergen-specific IgE antibody levels for 26 allergens using 200 microliters of patient serum. To evaluate the effectiveness of MAST-26 for the detection of allergen-specific IgE antibody, a total of 100 serum samples were collected from allergic patients at five facilities, and allergen-specific IgE antibody was measured by MAST-26. 14% of them were positive to > or = 10 allergens. If the patients had severe allergic symptoms, they were likely to show positive to many allergens. A good correlation was found between the results obtained by MAST-26 with those measured by CAP RAST and by intradermal skin test. It was concluded that MAST-26 is an effective screening method for the detection of allergen-specific IgE.

New EIA technique for tyrosinase in human melanocytes and its application

The expression of tyrosinase in melanocytes relates to skin pigmentation or depigmentation. Although many types of drugs with whitening effects are well known, neither the definite effect nor the mechanism underlying the effect has been elucidated. In this study, we attempted to develop the rapid and simple EIA technique for tyrosinase protein, then this technique was applied to normal human cultured melanocytes. When primary antibody and tyrosinase were incubated in non-coated 96-well microtitre plates for 48 hours at 4 degrees C, then the solution in tyrosinase-coated plate was further incubated for another 1 hour at 37 degrees C. Thus the best results were obtained. The developed EIA system could detect authentic tyrosinase until 0.1-1.0 ng/mL. This EIA technique could also be applied to human cultured melanocytes. The melanocytes cultured with endothelin-1 induced tyrosinase like immune reactive protein. The protein induction with endothelin-1 was suppressed by BQ 123, ETa receptor antagonists. The simple EIA technique developed for tyrosinase may give a clue to determination of the onset mechanisms underlying pigmental diseases of the skin as well as the mechanisms underlying the effects of various whitening drugs.

[Detection of extended spectrum beta-lactamases producing Enterobacteriaceae in feces]

A study was made of 366 feces for detection of extended spectrum beta-lactamases producing Enterobacteriaceae from feces. The selective agar was used for modified drigalski agar (Eiken Chemical Co., LTD) with 2 micrograms/ml cefotaxime (ESBL screen agar). 92 strains of Enterobacteriaceae, 41 Escherichia coli, 15 Citrobacter freundii, 13 Enterobacter cloacae, 11 Klebsiella pneumoniae, and other 12, were isolated from ESBL screen agar. And, R-plasmid that were selected by 2 micrograms/ml cefotaxime were transferred by conjugation from two of the 92 strains. These strain were E. coli TH9809927 and Proteus mirabilis TH9808262 that were amplified by "Toho-1 type" primer. The clude enzyme from two strains (donor) and transconjugants were especially hydrolysed cepharoridine and cefotaxime. Accordingly, two strains (0.5%) were detected as ESBL producers. We think that the result of our survey suggests the increase of ESBLs producing bacterial infection in Japan, and believe that there is a trend of infection of its by surveilance of the feces.

[A SHV-derived extended-spectrum beta-lactamase (SHV-12) produced by an Escherichia coli recovered from wound abscess in post operative case with rectal carcinoma]

A 62-year-old woman admitted for rectal carcinoma suffered from a post-operative bacterial infection. Oxy-imino-beta-lactams including cefotiam (CTM) and cefozopran (CZOP) were prescribed for this case, but the patient developed a wound abscess followed by peritonitis. She recovered from the bacterial infection after drainage and recurrent washing of the abscess. An ephemeral aggravation of infectious signs was observed just after creation of an artificial anus, and CZOP was again administered, and no evident bacterial infection occurred. The patient recovered, then was followed as an outpatient to date. A CAZ-resistant (MIC, > 16 micrograms/ml) E. coli was recovered from pus of her wound abscess. Since the CAZ-resistance decreased (MIC, 64 micrograms/ml-->0.13 microgram/ml) by the presence of clavulanate (CVA) in this isolate, this strain was speculated to be an extended spectrum beta-lactamase (ESBL) producer at an early stage of infection. A similar strain was also isolated from the feces. Therefore, we immediately took measures to block the nosocomial spread of this microorganism, and we succeeded in preventing a nosocomial outbreak of this strain. It was later confirmed by PCR analysis and DNA sequencing analysis that this CAZ-resistant E. coli strain produces an ESBL (SHV-5-2a = SHV-12). This is the first report of a case of infection with SHV-derived ESBL producing E. coli strain in Japan. We are concerned that further dissemination of this kind of microorganism might occur in the near future also in Japan, as it has been widely observed in European countries and the US. We believe that it will be very important to distinguish the type of beta-lactamases for rigorous bacterial infection control with the prudent use of antibiotics. In other words, we in Japan must recall that various gram-negative bacterial species that produce TEM-, SHV-derived ESBLs, Toho-1, AmpC, or IMP-1 are already widespread. Thus, we should take this fact into consideration when we do antibiotic susceptibility tentings and interpretation of the results for promotion of accurate chemotherapy.

[Quality control on antimicrobial susceptibility testings]

Performance of quality control in the clinical microbiological laboratory is markedly behind that of other laboratories. In particular, it remains indispensable even if the antimicrobial susceptibility test being carried out is standardized. In Japan, a standardized method of antimicrobial susceptibility testing has recently been established by the National Committee for Clinical Laboratory Standards and Japan Society of Chemotherapy. However, most laboratories do not perform quality control for antimicrobial susceptibility testing according to the standardized rules. The problem in quality control in laboratories causes things to remain as they are. As a review of laboratory quality control methods, we will show several cases of error that we encountered in our laboratory.

[Developmental changes of awareness during passive and active attentions: evaluation of serial event-related potentials (N130, N180, P250)]

Serial event-related potentials (ERPs), especially the negative components before P300, were recorded to evaluate the developmental changes of awareness, or intentional attention. In this study, 36 healthy children (5-16 years of age) and eight healthy adults (19-37 years) were told to perform two attentive paradigms: passive and active. Each test condition consisted of 16 electrical stimuli. Four trials were averaged in sequence and then evaluated as serial four blocks. With repetition in both passive and active attentive paradigms the amplitude of N130 was not attenuated until six years old. During active attention, N180 remained undiminished in adolescents and adults. The amplitude of P250 decreased with repetition during passive attention in children over seven years old, but was not attenuated during active attention in adults. These results suggest that N130 reflects the orienting reflex, and that N180 is associated with the process to maintain awareness.

[Quantitative measurement of prefrontal lobe volume on three dimensional magnetic resonance imaging scan]

This article describes the measurement of the frontal and prefrontal lobe volumes on three dimensional (3-D) MRI in 13 children aged 5 months to 14 years and in 3 adults aged 27 to 39 years. The 3-D MRI data were acquired by the fast spoiled gradient recalled (SPGR) sequence using a 1.5 T MR imager. The frontal and prefrontal lobe volumes were measured by the volume measurement function of the Workstation. We confirmed that this technique to analyze segmental brain volumes achieved acceptable levels of reliability and accuracy. There was an increase in the frontal and prefrontal lobe volumes with advancing age, being rapid between 8 and 15 years of age. The prefrontal to frontal lobe volume ratio also increased gradually, with spurts between 8 and 15 years of age. This approach may be particularly useful for studies on patients with frontal and prefrontal lobe dysfunctions.

Effect of beta-agonists on production of cytokines by activated T cells obtained from asthmatic patients and normal subjects

Intracellular levels of cAMP were found to regulate T cell activity. We examined whether beta2-agonists altered cytokine production and cyclic adenosine monophosphate (cAMP) accumulation in concanavalin A (ConA)-activated peripheral T cells from asthmatic patients. Procaterol and isoproterenol weakly decreased the ConA-elicited interleukin (IL)-4 and IL-5 secretion; however, the inhibitory effect of procaterol on the ConA-induced IL-2 secretion was inferior to that of isoproterenol in normal controls and was little in asthmatics. The intracellular accumulation of cAMP by procaterol was not altered compared with that by isoproterenol. Results suggest that there is a qualitative difference between procaterol- and isoproterenol-induced cAMP accumulation in T cells.